California POPTS Legislative Battle Continues to Gain Media Attention

The California Chapter's fight over Assembly Bill 783 continues to gain media attention, most recently on the KTVU morning news (FOX affiliate) in San Francisco. Despite massive opposition from the California Chapter concerning such physician-owned physical therapy services (POPTS) arrangements, and recent high-profile media coverage, the Assembly passed AB 783 May 12 by a vote of 66-0 (with 12 abstentions). The legislation now will be considered by the state Senate.

Assembly Bill 783, sponsored by Assembly Member Mary Hayashi and strongly supported by the California Medical Association, was introduced on February 17. The legislation would amend the California Business and Professions Code and the California Corporations Code to specifically add licensed PTs to the list of "healing arts practitioners" who may be employees of medical or podiatric medical corporations. The legislation is in response to an opinion issued by the State of California Legislative Counsel in 2010 that stated that based on existing law it is illegal for PTs to be employed by any professional other than naturopaths. In its opinion, the Legislative Counsel confirmed that, because the existing California Corporations Code does not specifically include PTs on the list of those who may be employed by a medical corporation, a PT is prohibited from providing physical therapy services as an employee of a medical corporation, podiatric corporation, or chiropractic corporation. This ruling means that PTs in these employment situations may be subject to discipline by the Physical Therapy Board of California.

Comments

Its disgusting that despite educating politicians and the public,having clear cut studies showing the conflict of interest of POPTS and its detrimental effect on patient care, with enough money you can get a 66-0 vote. Glad to know lobbying involves who can contribute the most money.

Posted by James Gregory
on 5/26/2011 2:23 PM

Until all licenced physical therapist and assistants join APTa and get involved we will continue to have problems with medicine and our pain Chiros. Every chiro is a member of the ACA. Not all therapist our APTA members. The change has to start within. Chiros should not sign PT POCs and many MD owned PT clinics are mills, but instead of pointing fingers, we must focus our real change within our profession.

Posted by Matthew
on 5/26/2011 9:41 PM

I am sooo tired of the POPTS issue. As a PT, I should be able to work in whatever scenario I choose. I work for a POPTS and believe that the patient care at my facility is second to none. Our physicians give patients the choice to go whereever they please to receive their PT. Yes, there is the possibility for a conflict of interest with a POPTS, but what is the difference when a PT owned facility hires ATC's for athletic coverage and streamline the athletes to their facilty without giving them a choice? The answer is none. We need to police ourselves and eliminate any unethical practice, but more importantly, we need to focus on more important issues of patient care like having the ability to see Medicare patients without a physician referral. Working with physicians can be a strong ally for our profession. Working against them will create more of a barrier regarding out Vision 2020.

Posted by Scott Gibson, PT
on 5/27/2011 1:05 PM

it is shamed

Posted by Chris
on 5/27/2011 1:06 PM

As a professional licensed Physical Therapist we should all ask ourselves the question, "is it ethical for me to work for someone that is referring pt's directly?" We as a group of knowledgeable, skillful practitioners, should not even be filling these job openings whatsoever. If anyone does work for one, I really question the integrity of that therapist.........

Posted by Adam Theesen
on 5/27/2011 1:14 PM

I own a physical therapy practice in a state which currently doesn't allow POPTS. However, our state association has to fight this battle almost every year in the legislature, as the medical association gets state representatives to continually introduce bills that would allow POPTS. Is it worth the battle? Should be just give up and let the big dog AMA lobbyists win? NO! We have to stand up for what's right and what's best for our clients. First of all, it is a complete financial conflict of interest for a physician to "own" a physical therapist. It leads to all kinds of abuses-- from over-prescribing PT to over-booking the therapist in order to make more money, thereby decreasing the quality of care. And, since the therapist is an employee, he/she has no freedom to point out these problems without fearing the loss of his/her job. In my state, occupational therapists can be employed by physicians. So, every patient that goes to the hand surgeon in my small town gets sent to the OT in his own office, despite the fact that this therapist is not the best or most experienced hand therapist in town and is not even a certified hand therapist! I can tell you right now, if POPTS were allowed in my state, my business would disappear within 6 months. Yes, this would be sad for me, but it would also be sad for my clients. I would be forced to go to work for a POPTS and would likely be pressured to see more and more clients per day and give poor quality care. Any high school economics student can tell you that competition, in any industry, improves the quality of the product and customer service. POPTS essentially eliminate any competition in the PT service industry and destroy the consumer-driven market that ensures only the highest-quality providers succeed.

Posted by Elizabeth
on 5/27/2011 1:34 PM

I believe a 66-0 vote is further indication that what is best for the people does not outweigh what is best for the politicians' campaign contributions. Until we put a firm limit on how long our legislators serve, their only concern is how they can stay in office. Be damn what is right for the country, they need to get paid...

Posted by Kevin
on 5/27/2011 1:50 PM

Just a thought @ "many MD owned clinics are mills"
I am not sure if it is worth pointing fingers at one place or the other. Personally I came across PT mills located in many places, including: home care, hospitals, and private practices. Simply, some clinic owners (whoever they are) will always try to maximize profit. And, there is no simple way to resist such an employer.
I wonder if change of our strategy could alleviate this situation? What could happen if instead of promoting autonomy of the profession, we would start promoting autonomy of a professional? In this scenario, each PT (self employed or employed) should bill for his/her individually provided professional service, and receive reimbursement into his/her account. The employer should be reimbursed only for the technical component of the service (even in environments reimbursed under PPS). Separation of technical and professional components will temper grid of unscrupulous employers. And, autonomy of individual provider will assure autonomy of the profession.

Posted by Anthony
on 5/27/2011 2:24 PM

Sadly, it is PT's who choose to work in conflicting interest arrangements that create this situation. And, in the face of APTA's 2020 vision for autonomous practice. As a private practice owner, we cannot compete with the salaries offered in these business arrangements. The almighty dollar wins out and our profession will continued to be compromised.
Meanwhile our government struggles to find wasted spending? If you can't walk the walk, don't talk the talk.

Posted by MaryEllen
on 5/27/2011 2:27 PM

Surely we are all against POPTS, but until therapists who own clinics are willing to treat their incoming PTs with professional respect like doctors and lawyers do, and allow them an opportunity to buy into the practice (very rare indeed), incoming PTs can make more money at POPTS and are therefore tempted to work there. This isn't just an external problem, it is also a problem of greed of private practice owners that results in an unwillingness to treat other PTs as professionals within our ranks. I fear prohibiting POPTS will only make the problem worse since there will be less choices for incoming PTs.

Posted by Burke Gurney, PT, PhD, OCS
on 5/27/2011 2:27 PM

Of course we all hate POPTS, but this is an internal problem as well. As long as PT owned clinic owners are unwilling to treat their incoming PTs as professionals the way that doctors, lawyers, architects, even some chiropractors do, i.e. allow them to form some sort of ownership/limited partnership, this problem will persist. As an incoming PT, often MD owned clinics are willing to pay the PTs more money, and thus some PTs who are trying to do what is best for them go there. If clinical owners provided a better alternative, this problem might well go away on its own. Just a thought.

Posted by Burke Gurney, PT, PhD, OCS
on 5/27/2011 2:46 PM

and what is the APTAs response to this?

Posted by rick carlson
on 5/27/2011 3:36 PM

Had a conversation with ortho doc from Fresno last week. He stated that they closed their PT clinic for a day last month so that they could all go to the Assembly meeting in Sac and lobby for POPTS as a legitimate enterprise. What he stated about the APTA's position was dissapointing - he stated that our defense included mostly disjointed ancedotal stories of how sub standard care was given to some patients of POPTS - in other words, minimal objective information. My question to our APTA is: Why are we not providing facts on increased utilization of PT (waste) that these business situations facilitate, and that the responsible thing to do to curtail health care costs is to not allow it to continue. Medicare (our government) has strict rules with PT treatment, and for good, objective reasons. Why are we not standing on these reasons rather than what can appear to be whining anectotal stories. Obviously with a 66-0 vote, we need to change the stradegy folks.

Posted by Chris Dahlhoff
on 5/27/2011 4:02 PM

We're engaged in a test of the integrity and value of our profession. We have to continue to strive to educate the public about our worth and contributions, and ownership is a piece of the battle. Many PTs (the majority) are employees and likely unaware of levels of conflict-of-interests CoIs) within their own organization(s). Arguments really revolve around peer relations and power structures within and between the professions. CoIs are ubiquitous in medicine, so this is a weak argument; however, COST and UTILIZATION of Services increases are strongly associated with physician-ownership. Efficient/effective healthcare is central to the new medical world order AND POPTS are not congruient with that model.
The future of healthcare in the US will likely involve integrated systems/organizations, which will include both PTs and physicians as employees. We're likely not to have a place at the table of the 'power' and 'profit sharing/risk sharing' if we continue our sink into ancillary roles. I'm reminded of the roots of the word ancillary: Origin:1660–70; < Latin ancill ( a ) ( see ancilla) + -ary; compare Latin ancillāris having the status of a female slave, with -āris -ar1.....very telling definition. (http://dictionary.reference.com/browse/ancillary)
What role do we want in the future of healthcare? Every PT should fight this legislation by any political means possible. Thank you. Britt

Posted by Britt Smith PT, DPT, OCS, FAAOMPT
on 5/27/2011 4:19 PM

Not all MD owned PT clinics are mills. If a PT is involved in running a "mill" then the PT should be disciplined. My moral and ethical principles were why I was recruited by the POPTS I currently work in. I frequently consult, at no cost to the patient, during office visits and recommend exercises and tactics to eliminate a pain problem or head off trouble before it reaches a point where regular PT is needed. I set the schedules for patients, and determine treatment frequency and duration.
Playing "Whackamole" with peoples' livelihoods in an effort to eliminate the opportunity to be a criminal eliminates the opportunity to not be a criminal as well.

Posted by Leon Richard -> AJSa@O
on 5/27/2011 5:27 PM

In response to the posts by people who work for POPTS and decry the statement that physician owned practices are mills, I have a response and a comment. I have no problem consulting with a physician, providing a free opinion and/or recommending exercises or tactics to eliminate a problem when I control my time and my expert services. If the physician truly values you as an equal member of the healthcare team, why can't you be an independent contractor and then you can decide what your time is worth and how you want to spend it? When another profession controls your services and also makes money for themselves every single time you see their patient, there is a conflict of interest and you are "less than". A general practitioner MD does not make money on a referral to as specialist. You may set your own schedule, but he/she still makes money when you see his/her patients. Research has shown that over utilization occurs in this model and eliminates choice. It is also true that independent private practice physical therapists are paid LESS per visit for services than if they are paid incident to a physician's services in their offices. It's not a level playing field. That is what we are asking for. I have been a physical therapist in private practice for over 20 years and I will put up my services and any of my well trained and expert staff, against any physician owned practice. We just need a fair opportunity to do this without the underlying conflict of interest. I have met with my legislator here in Ca and have given him the cost numbers, position papers from the APTA with quite a bit of objective data. He chose not to believe it or ignore it, whichever, it doesn't matter. Our lobby is small compared to the AMA. We don't have the numbers or the finances to fight on the same level but we need our own profession to understand the importance of this matter. How do you want to be perceived in the global picture of healthcare? Is our profession important? Essential? Who should provide the services and who should control it?

Posted by Karen Nugent,PT CHT IMTC
on 5/27/2011 7:35 PM

I think that this coin is definitally two-sided. I work in a POPTS situation, and I we provide, I believe, excellent care to all our patients. In addition, more often than not, we are trying to convince the physicians to send patients. I have been in this setting for 8 years, and have NEVER seen an inappropriate referral. We control our schedule, so we are NOT forced to overbook; we are allowed to spend the time we need with hands-on care, and we are in communication with the physicians constantly, which only enhances the care provided. Can I say this about all private practices and physical therapist-owned clinics? NO! I have seen the care that some of our patients, coming from those clinics have received. Which is better? Are we really trying to improve care for patients? I am appalled that the APTA is not supporting ALL physical therapists, not just those who they deem worthy, who are in private practice or non-physician owned areas. I do belong to the APTA, but if it continues to be a "us-vs.-them" mentality, I will not support the APTA any longer.

Posted by Lisa Gierczak
on 5/27/2011 8:05 PM

While I realize this is only my individual experience over 15 years of physical therapy practice the worst abuse occurred in a corporate setting where 4 patients were scheduled per therapist per hour with an expectation that each patient would be billed for at least 45 min of treatment. Other environments that I have worked in include therapist-owned clinics, physician-owned clinics, for-profit hospitals, not-for-profit hospitals, corporate owned skilled nursing facilities, and university based therapy clinic. The therapist-owned clinic was actually worse with regard to questionable ethical practice and maximizing profit at the expense of the working therapist. The difference with the physician owned clinic was the physicians also saw patients thereby generating revenue while the therapists who owned their own clinic sat in an office and NEVER treated patients.
With regard to choice of therapy clinics to attend, the patient is forced to choose from a clinic that is in-network. That clinic may or may not provide the "best" service locally. Therefore the consumer driven marketplace is already compromised.

Posted by Robbin
on 5/27/2011 9:53 PM

POPTS have ruined the profession of physical therapy. Profit is the motive and quality of care is taken out of the equation.To think otherwise is sadly naive.

Posted by joe napolitano
on 5/27/2011 9:57 PM

Karen- I could not have said it any better. There is not a level playing field and never will be with the AMA. And the biggest kicker is that private practice PT is reimbursed considerably less than POPTS- so we can never offer the same monetary compensation to our PTs. But we can offer a much better learning and working environment. And for those of you who think that private practice owners are greedy by not allowing their PTs to own part of the company, clearly you have no idea of the low reimbursement private practices get and the high overhead we are dealing with these days between health insurance premiums and PTs that are demanding top dollar. There isn't one PT in my practice who would even want that "opportunity" to be a co-owner. The problem should focus back onto the unethical problem that POPTS presents and what it ultimately does to our profession.

Posted by Juli Hunt, PT, DPT
on 5/27/2011 10:54 PM

I think we can all agree that there is the potential for abuse in EVERY practice setting. Hospitals pressure physicians to refer "in house". Nationally based Rehab companies pressure the managers to meet "Key indicators". Physician owners pressure PT's to treat inappropriate referrals. Home health PT's are pressured to see as many patients as possible. Private practioners have practice standards and can exert pressure on PT employees. The potential for abuse is rampant. The individual therapist has to have the professional intergrity to recognize when he/she is being asked to perform in an unethical manner no matter what the setting...its up to YOU...

Posted by Michael Leither
on 5/28/2011 12:12 PM

My goal is to provide quality physical therapy care to my clients, regardless of who "owns" the clinic. Let's remember it is the individual's choice to receive physical therapy, not the physician's! It's disheartening to me that we are so overwhelmed with the political, territorial and business disputes over patients than focusing on their care.

Posted by Chris
on 5/28/2011 1:17 PM

Integrity occurs on an individual basis. Individual people with/without integrity form organizations or companies with/without integrity. PT's like other professions can be influenced in a number of ways to act without integrity. This can occur in any practice setting. Therefore, we need a individual tracking mechanism to monitor functional outcomes and utilizaiton rates. This is the only way to weed out individuals who are found lacking.

Posted by Brad
on 5/29/2011 1:23 AM

The passing of AB 783 will allow for overutilization of Medicare and cost the tax payer more money. This essentially increases California's debit deficit. I strongly think the focus on AB 783 should be shifted from sub-standard of care to costing California tax payers more money. We should publicly advertise the message that any legislator voting for this bill, especially the one's up for re-election, would be saying they want to increase Medicare spending, increase taxes, and increase the California's deficit. I think the public should know who is deciding the welfare of their healthcare. I marched Capitol Hill and spoke with assembly members. They seemed concerned about the issue, but they were more concerned about passing the state's budget. We need to start speaking their language, and that would be dollar bills & their reputation.

Posted by Nicole Tetreault SPT
on 5/29/2011 1:14 PM

It is obvious that only those who work for POPTS find them acceptable. Over and over the studies indicate over-utilization and decreased choice and competition when fee for referral exists (this is true with outpatient hospital-owned facilities also - in my opinion it is a worse problem. Stark laws don't force hospital-owned physicians to give patients an option at all). If we really want to reform healthcare, cut costs and improve quality, we as a nation must decide to end all fee for referral situations.

Posted by Chris Z
on 5/30/2011 9:06 AM

Boy, so many firm positions/opinions and all reasonable with many unique experiences. I agree with the decision by the state congress, because the essence of the American economy is based on choice and free trade in any industry, even healthcare. If you have a person or entity willing to deliver a service, how skilled or unskilled to serve a demand, they should be entitled to.
Any problem of ethics/abuse is a matter of how it is policed. I strongly believe this is an issue between the seeker and the payer of the service. A gap exists between the two because of third party, insurance markets, private and government alike. They corner our health care disciplines. As providers, I'm glad we have the choice to participate or not. As a beneficiary, I'm not happy that we will not have the choice to be covered or not, but I understand the current federal effort to control 'uncovered' situations (just hope it's temporary).
My personal opinion is that we leave POPTS alone in attempting to make them 'illegal' and think it is a mistake for any governing body that does so. The upcoming efforts to combat fraud and abuse is seriously gearing up. As a provider, if you or if you work for an entity that does not provide therapeutic skill with decency and integrity, it will catch up to you.

Posted by Dave Bullock
on 5/30/2011 11:34 PM

It is not time to cry. Start doing brain storming
How to destroy POPTS. 1) good ways 2) bad ways
find their weak points and attack.These are not first people will attack our profession. All PT should be united . If there is no PT to work who they will employ. Physical therapy become cash cow for other people. We have to defend our profession
even you become DPT problem remain same. There should be professional safe guard in professional license
deepak PT

Posted by Deepak
on 5/31/2011 9:48 AM

The problem with POPTS is that is does not allow a free market for PT services, as long as physical therapists are not reimbursed by insurance companies for direct access and physicians continue to be the gate keepers for healthcare services. A PT practice owner is under constant pressure to agree with the rehab POC established by the referring physician for fear of losing a referral source.Even though the referring physician is not trained in rehabilitation.The APTA establised Vision 2020 to create autonomous practitioners of choice. The APTA takes a stance against POPTS because it supports PT's as ancillary services providers, not autonomous practitioners.

Posted by John Brees
on 5/31/2011 12:45 PM

Another angle: What about the hospital based clinic that is surrounded by nothing but POPTS? The outpt dept also feeds therapists through the weekend rotation in the hospital so that they can provide what the doctors all want- therapy every day. If the outpt dept closes then the inpatient therapy dept will be understaffed or overworked in order to provide the full day of weekend therapy. The worst part is, many in our area are owned by foreign Drs who staff them with therapists from their country of origin and just feed them all their patients. Most of these therapists never bother to join the APTA!

Posted by Mary Strimbu
on 6/6/2011 8:48 PM

What is the difference between a POPTS and a corporate run clinic that demands more patients, billing higher paying codes only, and churning through new grads to keep their costs down? I would work for the POPTS over the corporation any day of the week. Plus, the most unethical clinic I have ever been in is a private, PT owned clinic. Every situation can have the money grubbers.

Posted by Jon
on 6/15/2011 8:59 AM

I agree with Scott Gibson. I work at a POPTS and have total freedom as to when to discharge a patient when they have maximized progress and overall patient management. I do not have the corporate or private practice owner screening my productivity or feel the pressure to "hang on" to that patient to keep my volume up for the bottom line. There can be abuses in both situations, however the argument that POPTS are financially unethical is absurd. Its all about the money. I have more autonomy at a POPTS than I ever had at private practive or corporate clinic.

Posted by William Dean, PT, DPT, OCS
on 6/17/2011 3:35 PM

You have to be an MD to own a medical practice, you have to be an attorney to own a law practice, I feel you should be a physical therapist to own a PT practice. I have seen patient mills at POPTS and I have seen the same at Corporates but not every POPTS and Corporates are the same just like a private practice is not the same. Please do not assume that every private practice is the same. I bet that the AMA wouldn't want a PT running a family practice clinic either. The APTA frowns on PTs working for the POPTS and there is a good reason for this, I respect the APTA's decision on this. There is a conflict of interest! I have patients' that are told by the orthopedic to go to their PT clinic which 35 miles north of their home and it isn't right when our clinic 1/2 mile from their home. This happens too many times and our outcomes are outstanding compared to their patient outcomes because the patients' that go to their clinic and then end up at ours tell us so!

Posted by Phil
on 6/17/2011 8:36 PM

Do any POPTS employees know why physicians can not own pharmacies? Studies showed that physicians who owned pharmacies prescribed several times as many pharmaceuticals as physicians who did not own pharmacies. All PTs who care about autonomy should do all they can to create a situation in which patients will be referred for ethical reasons. Can you pretend that you as a POPTS PT are different than a pill? Work to be in a situation where our profession can advance because of its benefits. If another privately PT owned option does not work for you, create your own private option. Do not be another pill.

Posted by Dorothy Tevis
on 6/19/2011 3:58 PM

POPTS weaken our industry as a whole, plain and simple. POPTS are an extremely advantaged competitor to PT owned practices. To suggest otherwise is biased. It is the MD's power to steer patients into their own practice alone that creates conflict. However, more often than not MD practices are not mills, they just see a high volume of self supplied evals. They are the safe, cushy jobs that PT's above have talked about primarily cause the doctors don't have time for oversight. Other than financial impact, POPTS kill quality of care in the states they exist. Comparing the two states I have worked in , NY (no POPTS) and FL (POPTS), the quality of care is night and day. This is due to the fact that skill (being better than you neighbor)is eliminated in POPT situations. There is no incentive to be at your best when evals are guaranteed. There are two battle fronts of note in stopping POPTS or rendering them more harmless. Make it illegal to run POPTS or negate the necessity for an MD script for PT care.